Dr. Grcevich's presentation at Bioethics Conference and Through The Roof Summit, Cedarville University, September 17, 2011

1. Children and Youth Who Demonstrate Aggressive
Behavior at Church…What to Do?
Stephen Grcevich, MD
President, Key Ministry
Assistant Professor of Psychiatry, Northeast Ohio Medical University
Senior Clinical Instructor, Child and Adolescent Psychiatry
Case Western Reserve University School of Medicine
2011 Bioethics Conference and Through The Roof Summit
Cedarville University
September 17, 2011
Key Ministry, 8401 Chagrin Road, Suite 14B, Chagrin Falls, OH 44023
Phone: (440) 543-3400, E-mail: steve@keyministry.org
Web: www.keyministry.org Twitter: @drgrcevich

2. Download the Power Point from today:
 http://drgrcevich.files.wordpress.com/2011/09/gr
cevich-cedarville-through-the-roof-summit-
091711-aggression.pptx

3. Join us for Inclusion Fusion, the FREE Special
Needs Ministry Web Summit-November 3-5, 2011
Keynote Speaker:
http: www.inclusionfusion.org
Chuck Swindoll

4. Learning Objectives:
 Identify situations where kids may be more
susceptible to aggressive behavior during
church-based activities
 Share tools for ministry staff/volunteers to
reduce the potential for aggressive behavior in
church activities
 Review strategies for communicating with
parents after their child demonstrates
aggressive behavior
 Help parents, ministry staff/volunteers
appreciate each other’s perspectives in serving
kids with aggressive behavior

5. Subtypes of aggressive behavior:
Reactive aggression: Predatory aggression
 Affect: fear, anger  Affect: self-confidence
 Arousal level: high  Arousal level: low
 Outcome: negative  Outcome: positive for
 Impulsive self
 Reactive  Controlled
 Defensive  Predatory
 Overt  Offensive
 Hostile  Covert
 Instrumental
Vitiello B, Stott DM. J Am Acad Child Adolesc Psychiatry 1997; 36(3) 307-315

6. Definition of maladaptive aggression:
 Aggressive behavior that occurs outside an
acceptable social context
Maladaptive behavior is characterized by:
Intensity, frequency, duration and severity are
disproportionate to its causes
May occur in absence of antecedent social cues
Behavior not terminated in expected time frame, or in
response to feedback
Jensen P et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322

7. Characteristics of children, youth who
exhibit maladaptive aggression:
 More school adjustment problems than anticipated
 Higher rates of peer rejection, victimization
 Difficulty in ambiguous interpersonal situations
(reading emotion in facial expressions of others)
 More likely to read neutral facial expressions
negatively
 Poor peer relationships, deficits in problem solving
often emerge by age 4
 21% of children with impulsive aggression reported to
have been a victim of physical abuse (Dodge, 1991)
Dodge KA (1991) In: The Development and Treatment of Childhood
Aggression pp 201-218

8. Maladaptive aggression is frequently
associated with these common conditions:
 ADHD
 Bipolar disorder/SMD/DMD
 Autism spectrum disorders/developmental disorders
 Post Traumatic Stress Disorder
 Anxiety disorders/depression
 Iatrogenic causes
Aggression often co-occurs with specific
disorders, but may not be ameliorated by
medications used to treat those disorders
Jensen et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322

9. What situations at church may increase a child’s
risk for aggressive behavior (ADHD)?
 Transition times before and after children’s
worship
 Christian education activities when environment
is more chaotic, unstructured, supervision less
consistent
 Following high stimulation, high energy activities
 Evening activities (no orally administered ADHD
medication has been shown to consistently
produce effects longer than 13 hours)

10. What situations at church may increase a child’s
risk for aggressive behavior (Bipolar)?
 More reactive to seemingly innocuous stimuli
than kids with ADHD
 Episodic irritability in the context of preexisting
ADHD
 Speech: more, louder, faster
 More distractible, impulsive, hyperactive

11. Disruptive Mood Dysregulation Disorder (DMDD)
proposed in DSM-V:
 Characterized by severe recurrent temper outbursts in response to
common stressors
 Temper outbursts are manifest verbally and/or behaviorally, such as in
the form of verbal rages, or physical aggression towards people or
property
 Response is grossly out of proportion in intensity or duration to the
situation or provocation, child’s developmental level
 Outbursts occur at least three times/week for at least a year in two or
more settings
 Mood between episodes outbursts is persistently negative (irritable,
angry, and/or sad) and negative mood is observable by others (e.g.,
parents, teachers, peers)
 Chronologic age no younger than 6 (or developmental equivalent),
onset by age 10
DSM-V Task Force, American Psychiatric Association, 2011

12. What will kids with DMDD look like?
 They have ADHD
 They have difficulty with transitions that violate their
locus of control
 They tend to “ruminate”…indecisive, think too much
about things, perseverate…”meltdowns” occur when
they get stuck
 ADHD medication helps in some environments, may
exacerbate meltdowns in other environments
 They don’t do well with down time
DSM-V Task Force, American Psychiatric Association, 2011

13. What situations at church may increase a kid’s risk of
aggressive behavior: Autism Spectrum Disorders
 Initial experiences when family first visits
church-environment/routine is unfamiliar
 Changes in routine/unfamiliar people: “buddy”
off on Sunday morning, substitute small group
leader
 Excessive sensory stimulation
 Group situations may be more challenging for
middle school, high school youth

14. Three basic assumptions about
students in Sunday School/Church:
 Kids want to be competent, effective learners
 They feel upset when their behavior gets in the
way
 They fare better when they learn problem-
solving strategies

15. A word from one of our experts:

16. Keys to Behavior Management
 Before
 During
 After

17. Before…
 Pray
 Create your classroom/respite culture
 Encouragement
 Expectations
 Plan proactively
 Physical arrangement of the room
 Staffing
 Content of the lesson
 Pace of the lesson
 “In the event of an emergency…”

18. During: First line strategies
 Proximity Control
 Distraction
 Hurdle Help
 Antiseptic Bounce

19. During: Next steps
 “Grandma’s Law”
 Emotional Labeling
 Watch YOUR language
 Managing other students for safety

20. During: General Rule of Thumb
 When a child/youth is demonstrating aggressive
behavior that is predominantly impulsive in
nature, decreasing the sensory stimulation in
the environment is generally helpful
 When a child/youth is demonstrating aggressive
behavior that is predominantly perseverative
in nature, distracting the child as early as
possible before the pattern escalates is
generally helpful

21. After:
 Non-judgmental conversation
 Problem-solving
 Quiet
 Allow for “busy work”
 Re-join peers
 Communicate with parents

22. Struggles experienced by families of
children at risk of aggressive behavior:
 Demands on parents may limit time, energy for spiritual
growth, much less training their children in the faith
 Finding quality treatment resources for kids with
aggressive behavior is extremely challenging
 Approved treatments for aggressive behavior in kids
with ASD, bipolar disorder have very serious potential
side effects
 ADHD treatments are often associated with effects on
appetite, sleep, mood that necessitate medication being
withheld on weekends

23. Steps parents can take to enhance
collaboration with church staff, volunteers:
 Do share information with ministry team about techniques
shown to help prevent/reduce aggression at home and
school
 Do administer medication shown to help reduce frequency,
severity of aggressive behavior during church activities
(with approval of treating physician)
 Do be aware of the concern that aggressive behavior
presents in church settings with largely untrained
volunteers
 Doconsider (for the sake of other youth, volunteers)
keeping your child at home when he/she exhibits
aggression that you can’t successfully manage at home

24. What if a child/youth presents too great a
risk of severe aggression to attend church?
 What can the congregation do to support the rest of the
family in attending church, participating in activities key to
spiritual growth?
 Relational (home-based) respite
 Paid in-home child care/buddies with specialized training
 Scheduling church activities when appropriate care and
support for the child/youth is available
 Church as resource provider to parent…Whose
responsibility is the child’s spiritual development?

25. Conclusions:
 Kids with reactive aggression can generally be included
in existing church programming with appropriate
forethought and training
 Churches may reduce risk of aggressive behavior by
designing ministry environments that support kids and
youth who struggle to maintain self-control, providing
teachers and group leaders adequate training to identify
and intervene in potentially risky situations, and by
ensuring sufficient staffing at times of enhanced risk
 Traditional church may not be the “least restrictive
environment” for some children/youth especially prone
to aggressive behavior

26. Provides FREE training,
consultation, resources and
support to help churches serve,
welcome and include families of
kids with hidden disabilities

27. Stay in Touch!
Church4EveryChild…Steve’s Key Ministry Blog:
http://drgrcevich.wordpress.com
Diving For Pearls…Katie Wetherbee’s Key Ministry Blog
http://katiewetherbee.wordpress.com
http://www.facebook.com/drgrcevich
http://www.facebook.com/pages/Key-Ministry/116940088329098
http://twitter.com/#!/drgrcevich
http://twitter.com/#!/KeyMinistry
http://cmconnect.org/profile/StephenGrcevichMD

28. Questions?

29. Additional Resources:
Church4EveryChild…Steve’s Key Ministry Blog:
http://drgrcevich.wordpress.com
Relational Crisis Prevention and Making Room…Michael Woods
http://relationalcrisisprevention.com/
www.makingroom.net/